Drug Abuse in Iowa Evolving Issues & Emerging Trends

Iowa Office of Drug Control Policy

September 2016

1

Rapid Changes + Mixed Messages = ???s Evolving Risks involving Medicines, Synthetics, Marijuana, etc.

• What’s new (what is it, what’s in it, what’s it’s effect)?

• Does it heal or hurt (medicine or menace)?

• Is it legal or illegal?

• What do we tell children (or anyone else) about it?

• How is it different now, compared to what I experienced?

• What do we know about it & when will we know more?

• What’s next?

2

Youth Substance Use 40-Year Trends Current Use (past 30 days) Among U.S. 12th Graders

0%

10%

20%

30%

40%

50%

60%

70%

80%

3

Alcohol

Monitoring the Future, 1975-2015

Cigarettes

Marijuana

Drugs of Choice: All Iowans Primary Substance of Choice by Iowans in Treatment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Alcohol

Marijuana

Meth

Cocaine

Heroin

Other

6.3%

IDPH, 2014

4

50%

25.6%

14.8%

1.7% 1.6%

Iowa Youth Substance Abuse 6th, 8th and 11th Grade Users, Last 30-Days

0%

5%

10%

15%

20%

25%

2002 2005 2008 2010 2012 2014

Alcohol

Tobacco

Other Drug

Rx

OTC

Meth

3%

23%

12%

14%

9% 10%

6%

4%

3%

5

4%

Iowa Youth Survey, 2014

1% 1%

0

2

4

6

8

10

12

14

16

Marijuana Meth Rx Synthetic Opium Other

Iowa Drug-Related Traffic Fatalities Number Killed in 2014 Testing Positive for Illicit Drugs

6

Source: IDOT, 2014

Does not include alcohol-related fatalities.

Alcohol & poly-drug combinations were detected in some crashes.

15% of those killed in Iowa traffic fatalities

in 2014 tested positive for illicit drugs.

0

50

100

150

200

250

300

350

400

450

500

Iowa Drug-Impaired Driving 2015 Non-Alcohol Evaluation Findings by Drug Recognition Experts

7

IDPS, 2015

Iowa “Drug-Related” Prison Admissions Primary Drug Involved

0

200

400

600

800

1,000

1,200

8

Iowa Justice Data Warehouse, 2015

Rx Heroin

All

Drugs

Meth

Marijuana

Cocaine/Crack

Other

Iowa Drug-Related Child Abuse Confirmed/Founded Cases: Illegal Drugs in a Child’s Body

0

200

400

600

800

1000

1200

1400

1600

1800

633

IDHS, 2015

921

1,713

9

(Differential Response initiative began in 2014)

Alcohol & Tobacco/Nicotine

10

Iowa Annual Distilled Spirits Sales Millions of Gallons Sold to Adults

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

5.16 m

3.26 m

11

IABD, 2015

Excessive Drinking by Iowa Adults Percentage of Heavy or Binge Drinking by County

12

Robert Wood Johnston Foundation, 2013

Iowa Alcohol-Attributed Deaths & Hospitalizations

13

Iowa Substance Abuse Epidemiological Profile, 2012

Current Alcohol Use Last 30-Days

0%

10%

20%

30%

40%

50%

60%

70%

80%

12+ 12-17 18-25 26+

U.S.

Iowa

NSDUH, 2013/2014

14

Current Binge Drinking Last 30-Days

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

12+ 12-17 18-25 26+

U.S.

Iowa

NSDUH, 2013/2014

15

Iowa Tobacco-Associated Deaths & Hospitalizations

16

Iowa Substance Abuse Epidemiological Profile, 2012

Current Tobacco Use Last 30-Days

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

12+ 12-17 18-25 26+

U.S.

Iowa

NSDUH, 2013/2014

17

U.S. Youth Cigarette vs. E-Cigarette Use Last 30-Days

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

8th 10th 12th

U.S. Cigs

U.S. E-Cigs

Monitoring the Future Survey 2015

18

Iowa Youth Cigarette vs. E-Cigarette Use Last 30-Days

0%

2%

4%

6%

8%

10%

12%

6th 8th 11th

Iowa Cigs

Iowa E-Cigs

Iowa Youth Survey 2014

19

20

Marijuana

Marijuana/Cannabis a.k.a.

Now

21

• Hash or Honey Oil

• Wax or Earwax

• Budder

• Crumble

• Shatter

• Black Glass

• Edibles

• Reggie

• Loud

• Weed

• Grass

• Pot

• Reefer

• Hash

• Hemp

• Joints

• Blunts

• Buds

Then

Distinction with a Difference

22

Cannabis-Based Medicine:

Cannabis derivatives that test safe & effective as research-based

medicines for use by health care professionals in treating patients

with valid medical needs, & regulated to reduce public safety

risks.

Medical Marijuana:

Differing forms of cannabis approved by legislative or popular vote

in some states for treating various health conditions, with fewer

controls & safeguards than FDA-approved medicines.

Iowa Law:

Permits regulated use of limited quantities of CBD oil to treat

qualified patients with intractable epilepsy.

Marijuana Laws & Use by Teens by State

“Medical” & “Recreational” Marijuana Laws (2016 Governing.com)

Past Month Use by 12-17 Year Olds (2013-2014 NSDUH)

23

• Olive = “Medical” marijuana (*25 & DC). [OH June 2016]

• Lime = “Medical” & “Recreational” marijuana (4).

• Not Shown: Low THC non-psychoactive “CBD” oils (18,

including Iowa, where the Pharmacy Board recommended

in 2015 the Legislature consider rescheduling CBD only).

Health Group Positions on Marijuana

24

• Major public health organizations (American Cancer

Society, American Glaucoma Foundation, American

Medical Association, American Psychiatric Association,

National Pain Foundation, National Multiple Sclerosis

Society, National Association of School Nurses, et al.) do

not support smoked marijuana.

• The American Academy of Pediatrics “opposes marijuana

use by children & adolescents…the use of ‘medical’

marijuana outside the regulatory process of the

FDA…&…legalization of marijuana.”

Marijuana: R&D of Derivatives

25

Marinol (Dronabinol) & Cesamet (Nabilone):

FDA-approved synthetic cannabinoids—containing

THC & CBD—legally available as prescription pills to treat

cancer chemotherapy nausea & appetite loss.

Sativex (mouth spray):

A product with 2 cannabinoids extracted from the

cannabis plant failed FDA-authorized tests for

cancer pain, but may be tested on spasticity problems.

Epidiolex (oral liquid):

Contains the non-psychoactive cannabis extract

Cannabidiol (CBD), & is an FDA orphan drug in

a fast-track study to treat severe seizures. If all

goes well, an Rx product could be available by end of 2017?

Marijuana

66.3%

Alcohol

21.9%

Other 6.5% Meth

4.1%

Cocaine 0.2%

Opiates/Synthetics 1.0%

Iowa Youth Drugs of Choice Primary Substance by Juvenile Clients Entering Treatment

IDPH, 2014

26

Source of Marijuana Seized in Iowa 2015 Iowa State Patrol Significant Highway Interdictions

27

California

53.3% Colorado

40%

Wyoming

6.7%

Iowa was the 4th most

frequent state destination

for Colorado marijuana

seized in highway

interdictions in 2015. 2016 El Paso Intelligence Center

Iowa Department of Public Safety, 2015

Iowa Marijuana ER Visits Cannabis Use as Causal or Contributing Factor

28

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2006 2007 2008 2009 2010 2011 2012 2013 2014

1,633

455

Iowa Department of Public Health, 2014

Marijuana impairs/worsens respiratory systems,

heart rate, coordination, judgment, memory,

problem-solving & mood. It contributes to auto

crashes & can cause severe anxiety & psychosis.

Iowans’ Current Marijuana Use

29

Most Iowans are not current marijuana users (past 30 days).

Use

5.17%

Do Not

Use

94.83%

Use

5.02

%

Do Not

Use

94.98%

Iowa Youth 12-17 years old

currently using marijuana.

Iowans 12 & older

currently using marijuana.

2013-2014 National Survey on Drug Use & Health

Youth Marijuana Attitudes Among Iowa 11th Graders

0%

5%

10%

15%

20%

25%

30%

30

Iowa Teens Perceiving

No Risk Smoking Marijuana

Once or More a Week

Iowa Youth Survey, 2014

12%

24%

Youth Marijuana Attitudes vs. Use Among U.S. 12th Graders

0%

10%

20%

30%

40%

50%

60%

31

Perceived Risk of

Occasional Marijuana Use

Past Year Marijuana Use

Monitoring the Future Survey, 2014

College students daily marijuana use surpassed

cigarette smoking for the 1st time in 2014.

Marijuana Matters

32

• About 9% of marijuana users become addicted. That

number increases to 1 in 6 among users who start in

adolescence, & to 25-50% among those who use daily. 2012 National Institute on Drug Abuse, NIH, Drug Facts

• Drug-related student suspensions & expulsions increased

40% in Colorado schools from 2008/2009-2013/2014. 2015 Colorado Department of Education

• Persistent marijuana use during adolescence can cause a

long-term 8-point drop in IQ, & harm attention span &

memory. 2012 National Academy of Sciences, Dunedin Study

• College student daily marijuana use surpassed cigarette

smoking for the 1st time, increasing to 5.9%, the highest

level since 1980. 2014 Monitoring the Future Survey/University of Michigan

Marijuana’s Increasing Potency U.S. Seizures, Concentration of THC by % of Weight

0.74% 3.75%

11.8%

*50+%

0%

10%

20%

30%

40%

50%

60%

1975 1995 2014 *Recent

Co

ncen

trate

s

Sources: University of Mississippi Marijuana Project, NIDA & DEA

*Concentrates contain THC levels of 50-90%. (Examples: Hash Oil, Marijuana Wax, Marijuana-Infused Edibles)

DEA

33

Concentrates Beyond the Plant…

34

Concentrates Beyond the Plant…

“Budder”

“Shatter”

“Ear Wax”

“Green Crack”

wax

Hash Oil Capsules

Butane Hash Oil

(BHO)

35

New Marijuana in Iowa

36

Approximately 9.5% of

all 2015 marijuana

samples submitted to the

Iowa crime lab involved

marijuana “preparations,”

or “concentrates” (e.g.,

hash oils, waxes &

marijuana-infused

edibles).

2015 Iowa Department of Public Safety, Division of Criminal Investigation

9.5%

“Concentrates”

90.5%

Plant Materials

Iowa Marijuana Policy

37

• Marijuana, or a substance with *any amount of THC, is

illegal as a Schedule I Controlled Substance in Iowa (similar

to federal law).

• The 2014 Iowa Medical Cannabidiol Act (SF 2360) permits

very limited use of CBD oils that are *low in THC (<3%) to

treat intractable epilepsy.

• 25 states & DC have voter approved or legislated “medical”

marijuana; 4 states have voter approved “recreational”

marijuana; & 18 states, including Iowa, have CBD laws.

• Congress is considering proposals, including a Marijuana

Effective Drug Studies (MEDS) Act to promote research on

the medical effectiveness & safety of marijuana components.

Meth

38

Iowa Meth Labs

0

200

400

600

800

1000

1200

1400

1600

(Gold = “One Pot” Labs)

Iowa Meth Labs Down 90% vs. Peak of 10 Years Ago. Source: IDPS, 2015

39

1,500

2

151

Iowa Meth Purity Crime Lab Fiscal Year Averages

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008 2009 2010 2011 2012 2013 2014

Source: IDPS, 2014

35%

40

93%

Iowa Meth Treatment Admissions

0

1000

2000

3000

4000

5000

6000

7000

8000

Source: IDPH, 2014

7,196

41

4,062

Rate of Meth Treatment *ALL 12+ Substance Abuse Treatment Admissions for Meth

0

20

40

60

80

100

120

140

160

180

U.S.

Iowa

Iowa Meth Use Treatment Rate 3rd Highest in US (& 8th Highest Number). Source: TEDS 2012

42

47 per 100,000

169 per 100,000

*Clients reporting

meth as primary

drug of choice

Opioid

& Rx

Abuse

43

Types of Medicines Abused

• Opioids (*Pain Relievers) – OxyContin®, Vicodin®, Percocet®

• Stimulants – Ritalin®, Adderall®, Sudafed®

• Anti-Anxieties – Xanax®, Valium®

• Anti-Depressants –Prozac®, Zoloft®

• Sedatives – Rohypnol®, Nembutal®, Seconal®

• Etc.

44

*Synthetic Opioid Examples: Oxycodone, Morphine, Methadone, Codeine, Fentanyl & Hydrocodone.

Hydrocodone combination products became Schedule II Controlled Substances in October 2014.

45

National Rx-Heroin Trends

NIH, 2015

Drug overdoses, led by opioids,

claim 78 U.S. lives daily. CDC 2016

About 3 out of 4 new heroin users

report previous Rx opioid abuse. CDC 2016

Opioid OD Death Rates: 2002-2014

46

NLC-CDC, 2014

2002 2014

Drug Poisoning Death Rate per 100,000

47

CDC , 2010-1014

Iowa state rate of drug poisoning deaths ranks 44th ( 8.8/100,000)

Pain Reliever Prescriptions: By State

CDC, 2014

48

Controlled Prescription Drug Seizures In Dosage Units by Iowa Division of Narcotics Enforcement Agents

0

500

1000

1500

2000

2500

3000

3500

2009 2010 2011 2012 2013 2014

2,851 du

49

IDPS, 2015

Iowa Drug Treatment: Numbers Any Abuse of Non-Heroin Opiates & Synthetics Reported at Admission

0

500

1,000

1,500

2,000

2,500

3,000

2005 2006 2007 2008 2009 2010 2011 2012

2,506

764

TEDS, 2012

50

#1 “Exposure” call category:

Pain Medicines. Iowa Poison Control Center, 2016

Iowa Opioid-Related ER Visits Opioid Use (including Opiates & Others) as Causal or Contributing Factor

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2006 2007 2008 2009 2010 2011 2012 2013 2014

IDPH, 2014

1,555

51

519

Iowa Drug-Related OD Deaths: All Drugs

0

50

100

150

200

250227

46

Iowa Department of Public Health, Bureau of Health Statistics, 2016

52

118

*2015 Data is Preliminary

Iowa Opioid-Related OD Deaths: Rx & Heroin Rx = Pain Relievers (Rx Methadone, Other Opioids & Other Synthetic Narcotics)

0

10

20

30

40

50

60

70

80

90

77

5

Iowa Department of Public Health, Bureau of Health Statistics, 2016

53

43

1

15

20

Heroin

Rx Opioids

*2015 Data is Preliminary

Heroin

54

& Non-Medical

Synthetic Opioids (e.g., fentanyl analogs)

Hydrocodone

(Lorcet®)

= $5-$7/tab

Oxycodone Combinations (Percocet®) = $7-$10/tab

OxyContin®

= $80/tab

Heroin = $10/bag

Roxicodone®

Oxycodone IR

15mg, 30mg

= $30-$40/tab

Rx Pain Reliever-Heroin Connection

DEA, 2013

55

56

Rx-Heroin Trends

NSDUH, 2013

Heroin Seizures In Grams by Iowa Division of Narcotics Enforcement Agents

0

500

1000

1500

2000

2500

3000

3500

2009 2010 2011 2012 2013 2014

2,919.81 g

57

Iowa Department of Public Safety, Division of Narcotics Enforcement, 2015

12.68 g

Often mixed with heroin, black market

synthetic opioids (fentanyl, fentanyl acetyl-

fentanyl, furanyl-fentanyl, W-18, U-47700,

etc.) can be more potent & lethal than heroin

…& may be legal.

DEA, 2016

Drug-Related OD Incidents: Cedar Rapids

0

10

20

30

40

50

60

70

80

9080

CRPD, September 29, 2015

58

54

All Drugs

Heroin

Naloxone Use by Iowa EMS Providers # Times Administered

0

50

100

150

200

250

2010 2011 2012 2013 2014 2015

Iowa Department of Public Health, Emergency & Trauma Services, 2016

171 161

59

Almost 66% of 2015 Cases

Occurred in 30 Central & East

Central Iowa Counties

Ease of Access & Perceptions of Safety

60

Iowa PMP: Doses Dispensed Controlled Prescription Drugs, Schedule II-IV

0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

350,000,000

2009 2010 2011 2012 2013 2014 2015

303M+

228M+

Iowa Department of Public Health, Board of Pharmacy, 2016

61

The U.S. makes up < 5% of the world’s population, but

consumes about 75% of its prescription drugs…

including 81% of its oxycodone & 99% of its hydrocodone. UN

Response to Reduce Rx Abuse: Iowa Plan

62

Education & Intervention

Secure Storage & Safe Disposal

Monitoring

Enforcement

**NEW…Iowa Laws to Reduce Opioid Abuse & Deaths:

-SF 2218 & HF 2460 expand use of opioid overdose rescue drug Naloxone.

-SF 2102 allows Prescription Monitoring Program & EHR integration.

Safe Medicine Disposal

National Take-Back Events: Special take-back events are a good way

to remove expired, unwanted, or unused medicines from the home.

Law Enforcement Collection: A growing number of law enforcement

agencies collect expired, unwanted, or unused pharmaceutical controlled

prescription drugs on an ongoing basis via secure drop-off boxes.

Disposal in Household Trash: You may carefully mix medicines with

substances such as kitty litter or used coffee grounds and place them in a

container such as a sealed plastic bag to throw in your household trash.

Disposal by Flushing: A few medicines have specific instructions to

flush them down the sink or toilet when they are no longer needed.

ODCP, 2015

63

Pharmacy Collection: Some pharmacies collect expired, unwanted, or

unused pharmaceutical controlled prescription drugs from patients.

U.S. “Take-Back” Initiative Amount (in Tons) of Rx Drugs Collected

0

50

100

150

200

250

300

350

400

450

500

DEA, 2016

11 Events, 5.5 Years = 6,463,026

Pounds ( < 3,232 Tons! )

64

122

447

Next National Prescription Drug Take Back Day:

October 22, 2016

Iowa “Take-Back” Initiative Amount (in Pounds) of Rx Drugs Collected

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

DEA, 2016

11 Events, 5.5 Years = 69,019 Pounds

( > 34 Tons! )

65

1,569

9,084

Next National Prescription Drug Take Back Day:

October 22, 2016

Iowa Permanent Rx “Take Back” Sites Controlled Prescription Drugs

66

ODCP, 2016

odcp.iowa.gov/rxtakebacks

Sites doubled to 93 vs. year ago & are on pace to double again by January 2017.

Synthetic

Drugs

67

Synthetic Cannabinoids & Cathinones Hallucinogens & Stimulants by State

2010 2012

DEA, 2013

68

Phenylalkylamines

Benzodiazepines

Piperazines

Arylcyclohexamines

Tryptamines

Synthetic Cannabinoids

Ecgonine Derivatives

Anabolic agents

Designer Drugs

phenazepam

Benzyl-

piperazines

BZP

MDBP

4-Bromo-2,5-

diMeO-BZP

MBZP

MDBZP

Phenyl-

piperazin

es:

mCPP

TFMPP

MeOPP

pFPP

Steroids:

THG

Many

examples

SARMs:

Andarine

LGD-2226

Mk-2866

2C Series –

2,5-dimethoxy-

ethanamine:

2C-B

2C-C

2C-D

2C-E

2C-H

2C-I

2C-N

2C-P

2C-T-2

2C-T-4

2C-T-7

2C-T-21

25I-NBOMe

D-Series-2,5-

dimethoxy-

phenyl-

propanamines:

2,5-DMA

3,4-DMA

DOB

DOC

DOET

DOF

DOI

DOM

DON

DOPR

MDOB

Dimethoxy derivatives:

Monomethoxy

derivatives

PMA

PMMA

N-ethyl-PMA

Trimethoxy

derivatives:

3,4,5-TMA

TMA-2

TMA-3

TMA-4

TMA-5

TMA-6

4-MTA

homologs

4-MTA

4-MTMA

4-MTEA

4-MTPA

4-MTBA

4-MTDMA

b-Keto-

phenethylamines

Mephedrone

MDPV

Methylone

Ethylone

Butylone

Flephedrone

Methcathinone

Ethcathinone

bk-MDDMA

Naphyrone

4-MEC

4-EMC

a-PVP

4-MePPP

a-PBP

buphedrone

Difurnanyl

compounds

Bromo-

dragonfly

2C-B-fly

Fluoro-

containing

compounds

4-FA

3-FA

2-FA

N-Methyl-4-FA

N-Ethyl-4-FA

3-F-4-MeO-A

Others

MDDMA

Ethyl-

amphetamine

N-OH-MDMA

MDDM

N,N-Dimethyl-1-

phenyl-2-

ethanamine

1-phenyl-2-

butylamine

MDA

AMT

DMT

DET

DPT

DBT

DiPT

MiPT

4-OH-DiPT

4-OH-MiPT

4-OH-MET

5-MeO-AMT

5-MeO-DMT

5-MeO-DiPT

5-MeO-MiPT

5-MeO-EiPT

5-AcO-DiPT

5-MeO-DPT

5-MeO-DALT

Classic

cannabinoi

ds

HU-210

IP-751

Parahexyl

and many

others

Cyclohexyl-

phenols

CP-47,497

CP-47,497-

C8

CP-55,950

Indoles/Pyrr

oles

JWH-018

AM2201

JWH-200

JWH-081

JWH-250

AM694

RCS-4

SR-18

UR-144

XLR11

Eicosanoids:

Anandamide

Oleamide

Others

AKB48

URB597

CB-13

4-Fluorotropa-

cocaine

b-CFT

p-FBT

Red = Controlled substance

Yellow = Positional isomer, controlled by definition

Green = Determined to be controlled substance analogue

PCPR

PCMPA

PCMEA

PCEEA

PCEPA

5-MeO-

PCP

MXE

4-Me-

PCP

3-MeO-

PCE

69 Modified from Wohlfarth and Weinmann, Bioanalysis, 2010

69

The Chemistry

Synthetic Opioid Alert

Dangers of Fentanyl & Fentanyl Analogues/Compounds

Fentanyl is commonly laced in heroin, causing significant

problems across the country, particularly as heroin abuse

has increased.

Drug incidents & overdoses related to fentanyl are occurring

at an alarming rate throughout the U.S. & represent a

significant threat to public health & safety.

Often laced in heroin, fentanyl & fentanyl analogues

produced in illicit clandestine labs are up to 100 times more

powerful than morphine & 30-50 times more powerful than

heroin.

70

Drug Trends in Iowa: Summary

• Alcohol remains Iowa’s most abused addictive substance.

• Iowans’ appetite for meth remains strong, fed by cartels.

• Marijuana is Iowa’s most used illicit substance, & is

morphing into new more potent forms.

• Medicine/Opioid abuse is Iowa’s fastest growing form of

substance abuse…leading to more heroin use too.

• Synthetic drugs are a fast-changing threat to Iowa youth.

• With exceptions, Iowans generally abuse drugs at rates

below many other states…& Iowa youth substance abuse

is declining. Challenges remain, now & in the future.

71

SHARE THE NEWS & STAY SAFE!

Iowa Governor’s Office of Drug Control Policy

Visit Our New Website: https://odcp.iowa.gov

72